The Role of Colposcopy in the Diagnosis
Of VIN and Early Vulvar Cancer

A. Basta and K. Adamek
Chair and department of Gynecology and Oncology
Collegium Medicum Jagiellonian University, Cracow, Poland.


Summary
The value of colposcopy evaluation such vulvar lesions is underrated by many gynaecologists. The aim of the paper is to evaluate colposcopy usefulness in diagnosis of VIN and early vulvar cancer (stage I according to ISSVD.) The clinical material was consisted of 153 women aged 23-71 The cervix, vagina and vulva were evaluated colposcopically. Hig agreement (about 80 %) between cytological, colposcopical and histological examination also revealed since colposcopy enables more exact placement of punch biopsy.

Introduction
Recently a lot of data has been published on the increasing incidence of Vulvar Intraepithelial Neoplasia (VIN) and vulvar invasive squamous cancer, also in young women in reproductive age (1,2,3,4,10,14,16).
Epidemiological, histological and molecular studies show that VIN and invasive squamous carcinoma in younger women often coexist with sexual transmitted diseases, including the human papillomavirus (HPV) infection. In older women, VIN and vulvar invasive squamous cancer are, in a high percentage af cases, accompanied by vulvar squamoepithelial hyperplasia or lichen sclerosus (2,3,6,8,16).
The significance of colposcopy in the diagnostic procedure of HPV infection, precancerous and early invasive cervical cancer lesions is generally appreciated. The value of colposcopy evaluation of vulvar lesions is underestimated by many gynaecologists. The aim of the paper is to evaluate colposcopy usefulness in the diagnosis of VIN and early vulvar cancer (stage Ia and Ib according to the FIGO classification).

Table 1: Clinical Material 

VIN 1      VIN 2      VIN 3     CaIa      CaIb       Total

N                 41            40           36            6           30          153

%                 26.8         26.1        23.5         3.9        19.6        100

 Material and Methods

The clinical material consisted of 153 women aged 23 to 71 in whom VIN or vulvar cancer stage I had been found. Table 1
In all cases cytological, bacteriological and fungous examination of material collected from the vulvar surface as well as cervico-vaginal smears were performed. Very careful colposcopy evaluation was performed not only of the vulva and perineum, but also the vagina and vaginal portio of the uterine cervix. During colposcopy examination 5% acetic acid, iodineand toluidine (within vulva only) tests were carried out. VIN and vulvar cancer stage I (Ia and Ib) were detected during the course of the histological examination of colposcopy directed biopsy or surgical specimens (collected during local excision procedure or vulvectomy).
HPV infection was detected in 57 cases by in situ hybridisation.

Results Are Presented in Tables

Table 2: Colposcopy pictures of VIN and stage I invasive carcinoma in 153 women. 

                                            VIN 1+VIN 2                 VIN 3                Ca I

Colposcopy Picture                                n         %                    n     %               n        %

Foci of primary and secondary          48       59.3                     1     2.8                -

Transparency diminution

Punctation and mosaic areas located

Mainly in the vagina vestibule and    10       12.3                          -                     -

Samll pudendal lips

Papillomatous or initial papillomatous

Growth with secondary transparence   16     19.8                     2     5.6              -

diminution               

Thick layer of leucoplakia                      5        6.2                  16    44.4             6       16.7

Papiloma with indistinct structure

and strong secondary transparence

disminution                                            2         2.5                  10    27.8             9        25

Bowen-like yellow-bluish nodules                      -                     7   19.4                          -

Initial ecsophytic and endophytic growth

With atypical vessels and/or toluidine

Positive test                                                         -                             -                21     58.3

Total                                                      81        100                 36    100             36    100

 

Table 3: Localisation of VIN and Ca st. I within the vulva vs. age

            Localisation                 Women<45 years                    Women >45 years

                                                 n                      %                   n                        %

 

Unifocal                                   25                 37.3                 61                      70.9

 

Multifocal                                42                 62.7                 25                      29.1

 

Total                                         67                 100                  86                     100

  In 12 cases (17.9 %) VIN or vulvar carcinoma coexisted with intraepithelial neoplasia and/or invasive lesions within vagina and/or uterine cervix.
Table 2, Table 3, Table 4, Table 6

Table 4: HPV infection vs age.

                                               Women<45 years                    Women >45 years

                                                 N           n             %                   N            n               %

 

HPV Infection                        26          15           57.7                 21           4             

 

Table 5: VIN and vulvar cancer stage I coexisiting with epithelial hyperplasia or lichen sclerosus vs age. 

                                               Women<45 years                    Women >45 years

 Epithelial hyperplasia

or lichen sclerosus                   n                      %                   n                        %

 

Present                                   11                 16.4                 62                      72.1

 

Absent                                   56                 83.6                 24                      27.9

 

Total                                      67                 100                  86                     100

 

Table 6: The agreement between colposcopy, cytology and histological examination 

Histological examination

                                                     Agreement                           Disagreement

                                                n                      %                   n                        %

 

Cytological examination        124              81.1                 29                      18.9

Colposcopical examination    137              89.5                 16                      10.5

 Discussion

Colposcopy evaluation of the vulva lesions depended on the lesion localisation within the vulva, i.e.1) within the vulvar skin covering large pudendal lips and perineum or 2) within the mucosa of the vagina vestibule, clitoris and internal surface of the small pudendal lips.
In the case of lesion localisation within the skin, colposcopy mainly enables us to evaluate the epitehelium architecture. In the second localisation, colposcopy makes it possible to evaluate not only the epithelium, but also the subepithelial vascular bed.
The colposcopy pictures suggesting the lower stage of VIN (VIN-1 and VIN –2) are: foci of primary and secondary transparency diminution, papillomatous or initial papillomatous growth with secondary transparency diminution, and first step pathological vessels such as punctation and mosaic. These pathological vessels are situated mainly in the vagina vestibule, clitoris and small pudendal lips. The estimation of these lesions, especially subepithelial vessels are limited in cases when VIN coexists with nonneoplastic disorders of the vulva, such as epithelial hiperplasia and lichen sclerosus. It refers to 72.1 % of women in the peri-and post menopausal periods. (Table 5). Thick layer of leucoplakia, papilloma and verrocous lesions with indistinct and strong transparency diminution after acetic acid, Bowen –like yellow bluish nodules are correlated with VIN 3 and stage I carcinoma. Pictures of initial endophytic and ecsophytic growth with atipical vessels and/or toluidine positive test correlated only with early stages of carcinoma (stage I carcinoma). In the opposite to the other works (9) we did not confirm the usenfulness of toluidine blue test in the diagnosis of VIN. In the present study, a positive toluidine test was observed only in cases of invasive lesions. The high percentage of VIN and the invasive changes reveals multifocal localisation, especially in young women (62.7 %). There is also a relatively high percentsage of coexistance of VIN, VAIN and/or CIN in patients below 45 yr. It confirms the usefulness of colposcopy in diagnostic procedure of low female genital tract.
The high percentage (89.5%) of agreement between colposcopy and histological examination confirms the diagnostic value of colposcopy what is comfirmed by other authors’ as well (7,12,13) This fact obliges us to precise colposcopical evaluation of the entire lower female genital tract.
Summing up, it should be emphasised that colposcopy, which is often called vulvoscopy is a safe, non-invasive and cheap technique of detecting areas of atypical epithelium. In spite of some limitations of vulvoscopy application, the method enables more exact placement of punch biopsy within the vulva. It is very important especially in young women in whom VIN and invasive cancer are often multifocal, and coexist with the foci of intraepithelial neoplasia within the vagina (VAIN) and/or uterine cervix (CIN). The vulvoscopy should be an integral part of each gynaecological examination.
These observations indicate that colposcopy plays a special role in diagnostic management and enables the choice of proper therapeutical procedure.

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